Pregnant Patient Intake & Assessment Form PERSONAL Name: Mrs Ms Miss Dr (Please circle) (Last) (First) (Middle) Address: Postal Code: Telephone Numbers: ( ) (Home) ( ) (Cell) Email: Permission to send email/text appt. reminders & e-newsletter? (Y or N) Date of Birth: (MM/DD/YYYY) / / Age: Marital Status: Height: Weight: Spouse s Name: Number & Ages of Children: Emergency Contact Name: Telephone: ( ) Occupation/Profession: Employer: CareCard Number: Private Health Insurance: How were you referred to our Clinic? HEALTH Previous Chiropractic care? (Y or N) By Whom? When? Have you had X-rays taken? (Y or N) If yes, Date Taken: Area/Results: Doctor/Midwife: Do you consent to your findings being shared with your Doctor/Midwife? (Y or N) Date of Last Medical Appointment: Date of Last Physical: How many weeks gestation is your baby? Due Date: How many pregnancies have you had? Vaginal Delivery Caesarean Section Forceps Vacuum extraction Anaesthesia used? (Y or N) If yes, what type Please explain any complications with this or past pregnancies Smoker? If yes, how many/packs per day? Drink coffee? If yes, how many cups per day? Drink soft drinks? If yes, diet or regular? How many cups per day? Drink Tea? (herbal or caffeinated) If yes, how many cups per day? How many cups of water per day? Eat a balanced diet? (Y or N) Sleep at least 8 hrs a day? (Y or N) PRIMARY AREA OF CONCERN: Breech presentation Backache of Pregnancy Headache Trauma Other Please explain Please indicate on the diagram on the right where you have pain/symptoms. Describe the area of concern/pain (tingling, numb, sharp, burning, tender, stiff, sore, etc.): How did your problem begin? My pain/discomfort is now: 0 ---------------------------------------------5---------------------------------------------- 10 (indicate with an X on the scale) (No pain) (Worst pain) Please indicate if you have (had) any of the following conditions: Aneurysm Stroke Cancer Heart Conditions Diabetes Polio Epilepsy Multiple Sclerosis Muscular Dystrophy Lupus Hepatitis VD/STD/HIV/AIDS Psoriasis Eczema Eating Disorder Loss of Appetite Anemia Unexplained Bleeding High/Low Blood Pressure Thyroid Conditions Breathing/Lung Conditions Allergies Sinus Conditions Loss of Smell Sore Throat Difficulty Swallowing Stomach Conditions Indigestion/Reflux Ulcers Liver Conditions Gall Bladder Conditions Intestinal Gas/Bloating Constipation Diarrhea Kidney Conditions Urinary Tract Conditions Menstrual Irregularity Menstrual Cramps/Pain Reproductive Disorders Fatigue Cold Sweats/Fever Sleeping Difficulty Nerves /Anxiety Depression Irritability Loss of Memory Dizziness/Vertigo/Fainting Loss of Balance Concussion Ringing in Ears/Hearing Loss Ear Pain Vision Problems Light bothers Eyes Jaw Clicking Clenching/Grinding Teeth Headaches Migraines Tight Muscles Flushing of Face Twitching in Face Grating in Neck Head feels too Heavy Muscle Spasms Osteoporosis Painful Joints Arthritis Pins & Needles/Numbness in Hands/Feet Swollen Hands/Feet Cold Hands/Feet Ankle/Foot Problems Restless legs Varicose Veins Broken Bones Dislocated Joints Herniated Disc(s) Pinched Nerves Other Have you ever had any falls, accidents, or injuries? (Y or N) When? If yes, please explain Have you ever had surgery? (Y or N) When? If yes, please explain Are you presently taking any medication and/or vitamins? (Y or N) If yes, please explain One full day s notice is required for cancellation of appointments. (Patient s Initial)
Health Objectives Questionnaire What are your health objectives? Have you ever been put on a health development program by a health practitioner? Yes No If yes, by whom How long were you able to stay on the program? What were your results? Are you healthier today than you were 5 years ago? Yes No My health has not changed If yes, what have you done to improve your health? If no, why do you think your health has declined? Do you think your health will be better 5 years from now than it is today? Yes No I don t expect it to change If yes, what do you plan to do to improve your health? Do you think there is anything you can do to prevent your health from declining? Please elaborate Do you exercise and stretch regularly? Yes No If yes, what do you do, how often, and how long? Do you currently wear orthotics? Yes No If yes, type and how long? Page 2 of 6
Consent to Chiropractic Treatment It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an informed decision about proceeding with treatment. Chiropractic treatment includes adjustment, manipulation, and mobilization of the spine and other joints of the body, soft-tissue techniques such as massage, and other forms of therapy including, but not limited to, electrical or light therapy, and exercise. Benefits Chiropractic treatment has been demonstrated to be effective for complaints of neck, back and other areas of the body caused by nerves, muscles, joints and related tissues. Treatment by your chiropractor can relieve pain, including headache, altered sensation, muscle stiffness, and spasm. It can also increase mobility, improve function, and reduce or eliminate the need for drugs or surgery. Risks The risks associated with chiropractic treatment vary according to each patient s condition as well as the location and type of treatment. The risks include: Temporary worsening of symptoms Usually, any increase in pre-existing symptoms of pain or stiffness will last only a few hours to a few days. Skin irritation or burn Skin irritation or a burn may occur in association with the use of some types of electrical or light therapy. Skin irritation should resolve quickly. A burn may leave a permanent scar. Sprain or strain Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks with some rest, protection of the area affected, and other minor care. Rib fracture While a rib fracture is painful and can limit your activity for a period of time, it will generally heal on its own over a period of several weeks without further treatment or surgical intervention. Injury or aggravation of a disc Over the course of a lifetime, spinal discs may degenerate or become damaged. A disc can degenerate with aging, while disc damage can occur with common daily activities such as bending or lifting. Patients who already have a degenerated or damaged disc may not have symptoms. They may not know they have a problem with a disc. They also may not know their disc condition is worsening because they only experience back or neck problems once in a while. Chiropractic treatment should not damage a disc that is not already degenerated or damaged, but if there is a pre-existing disc condition, chiropractic treatment, like many common daily activities, may aggravate the disc condition. The consequences of disc injury or aggravating a pre-existing disc condition will vary with each patient. In the most severe cases, patient symptoms may include impaired back or neck mobility, radiating pain and numbness into the legs or arms, impaired bowel or bladder function, or impaired leg or arm function. Surgery may be needed. Stroke Blood flows to the brain through two sets of arteries passing through the neck. These arteries may become weakened and damaged, either over time through aging or disease, or as a result of injury. A blood clot may form in a damaged artery. All or part of the clot may break off and travel up the artery to the brain where it can interrupt blood flow and cause a stroke. Many common activities of daily living involving ordinary neck movements have been associated with stroke resulting from damage to an artery in the neck, or a clot that already existed in the artery breaking off and travelling up to the brain. Page 3 of 6
Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because an artery was already damaged and the patient was progressing toward a stroke when the patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke. The consequences of a stoke can be very serious, including significant impairment of vision, speech, balance and brain function, as well as paralysis or death. Alternatives Alternatives to chiropractic treatment may include consulting other professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment. Questions or Concerns You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor s attention. If you are not comfortable, you may stop treatment at any time. Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment. I hereby consent to chiropractic treatment as proposed to me. NAME (Please Print) Date: 20 SIGNATURE OF PATIENT (OR LEGAL GUARDIAN) Date: 20 SIGNATURE OF CHIROPRACTOR CCPA 12/2014 Page 4 of 6
Terms of Acceptance When a patient seeks chiropractic health care and we accept such a patient for care, it is essential for both to be working towards the same objectives. Chiropractic has only one goal: to eliminate spinal misalignments (subluxations) that interfere with the body s natural healing ability. The Chiropractor s sole purpose is to restore health through the natural flow of energy in the nervous system, to give the body the maximum opportunity to heal itself. It is important to understand what to expect from chiropractic in order for you, the patient, to determine whether it may be of benefit to you. A Chiropractor conducts a specialized spinal examination and analysis for the express purpose of determining whether there is evidence of spinal subluxations. When such subluxations are found, chiropractic adjustments are given to restore proper spinal alignment and function. Due to the complexities of nature, no Chiropractor can promise you specific results this depends on the recuperative powers of your body. We do not offer to diagnose or treat any disease or condition other than subluxation. However, if during the course of chiropractic spinal examination we encounter nonchiropractic or unusual findings, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what this disease is called, we do not offer to treat it. Nor do we offer advice on the treatment prescribed by others. Every chiropractic patient should be mindful of his/her own symptoms and should secure a medical opinion if he/she has any concern as to the nature of his/her illness or injury. In rare cases, underlying physical defects, deformities, or pathology may render the patient susceptible to injury. The Chiropractor, of course, will not give a chiropractic adjustment if he/she is aware that such a condition exists. It is the responsibility of the patient to make it known if he/she is suffering from any latent pathological defects, illness, or deformity that might not otherwise come to the attention of the Chiropractor. The patient should not look to the Doctor of Chiropractic for in-depth diagnostic procedures other than to find subluxations. This is the most important difference between chiropractic and medicine. Our only practice objective is to promote natural health through the release of maximum nerve energy. Our only treatment is by specific chiropractic adjustments to correct vertebral subluxations. I, have read and fully understand the above statements. PRINT NAME All questions regarding the Chiropractor s objectives pertaining to my care in this office have been answered to my satisfaction. I, therefore, accept chiropractic care on this basis. SIGNATURE DATE If applicable, SIGNATURE OF PARENT OR GUARDIAN Page 5 of 6
Assignment Of Medical Services Plan Benefits To Opted-Out Practitioners I, (Beneficiary) authorize the Medical Services Plan of BC to pay Dr. Stacey Michelle Rosenberg, D.C. (Practitioner) directly for all reimbursements for benefits payable to me under the Medical and Health Services Regulation for care provided to me by said Practitioner. I make this assignment in full knowledge of the amount that I will be personally responsible for and the amount that is reimbursable by the Medical Services Plan of BC, which will be directed to Dr. Stacey Michelle Rosenberg, D.C. (Practitioner) to be applied against any outstanding monies I owe for services provided. MSP Practitioner#: 21127 MSP Payment#: 21127 Name of Patient: (Please Print) PHN of Patient: (Care Card Number) Dear Patient: This form allows the above named practitioner to receive your MSP reimbursement directly for services that are MSP benefits. Your practitioner, by law, must advise you of his/her full fee and what portion will be reimbursed by MSP. By agreement, your practitioner may not charge you the portion reimbursed by MSP. Signature of Patient: Date Signed: